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mental health » Women's Courage

Archive for the ‘mental health’ category

PTSD and Victims of Sexual Violence

February 16th, 2011

My husband and I were sleeping in our house. The children were sleeping in the house next door. The soldiers arrived and brought my daughter to our house where they raped her in the presence of my husband and me. Afterwards they demanded that my husband rape my daughter but he refused so they shot him. Then they went into the other house where they found my three sons. They killed all three of my boys. After killing them, two soldiers raped me one after the other.

~Quote from “Now the World is Without Me”, a report by the Harvard Humanitarian Initiative, April 2010

“There is no precedent for the insensate brutality of the war on women in Congo. The world has never dealt with such a twisted and blistering phenomenon.”

- Stephen Lewis, co-director of AIDS-Free World

This week’s discussion on refugee situations and human rights really prompted me to investigate how horrific experiences like these can impact women’s mental health and explore cultural repercussions. What are the symptoms that these victims experience, and how are they addressed within a community? What type of organized health care response is in place and what are some new interventions? These are a couple of questions that guided my investigation and decision to specifically focus on women from Democratic Republic of the Congo (DRC), and discuss the lack of support system currently afflicting them.

Briefly, I’d like to give some context regarding the situation in the DRC. Following years of civil wars and involvement with conflicts in Rwanda, peace accords were finally signed in 2003 and a transitional government was placed until a new government was elected. However, fighting and terrorism continued on the eastern side of the country, where currently the prevalence of sexual violence is considered to be the worst in the world.

It is during these fighting flares that women are exposed to sexual violence and rape, often very brutal, as a weapon of war. This type of sexual violence has become commonplace in the eastern DRC, but humanitarian workers state that the situation is becoming much more violent and common, yet international response consists of mere “lip service”. In places where militia groups are present and fighting continues to subsist, reports of sexual violence are numerous, including gang rape, sexual slavery, purposeful female genital mutilation, and murder of rape victims. In some cases, family members are forced to watch the woman be so blatantly dehumanized and suffer from trauma as well. 40% of women interviewed for a study had been raped and over 50% of civilians showed PTSD symptoms in the study population. These results are striking, and yet I believe they only scratch the surface of the problem at hand.

The consequences of this gender-based violence results in high numbers of women confronting trauma, unplanned pregnancy, and STIs/HIV. Owing to the brutal nature of these attacks, women and girls suffer debilitating damage to their reproductive systems including multiple fistulae, broken bones, and severed limbs. The intensity of these attacks has life long impacts that can leave a woman disabled and unable to care for herself or her family. What is more, about 50% of these women also experience mental health issues like depression and PTSD at some point in their lives, leading to suicidal thoughts and actions. As some of you saw from the movie, A Walk to Beautiful, the severe impact of living with a fistula cannot be understated when young women would consider killing themselves before returning to their village, only to live in exile and feel like they cannot fulfill their role as a woman.

These conditions are all difficult to manage and many of these women turn to their families and communities for support or assistance in seeking health services. However, following experiences of sexual violence, about 30% of these women face rejection and stigma associated with the rape that can result in their husbands abandoning them or their social status within the family being lowered due to this perception of being “contaminated.” This contamination is perceived as both a moral and physical quality, the latter being more difficult for men to overcome. This is because of the fear of STIs and HIV since many of these women are gang raped and are thus at a very high risk for infection. In these situations, having a health care worker have a dialogue with family members may prove useful in eliminating prejudices about rape and encouraging support for victims of sexual violence.

What happens when your only support group does not want you to return, or decides that your voice no longer matters? The psychological distress that women experience after sexual violence can be greatly aggravated by the breakdown of their usual support system and the absence of a safe and supportive environment that is necessary for healing. Women suffering from PTSD experience several symptoms like feel nervousness, sleep disturbances, phobias, substance abuse, depression, social withdrawal, sexual dysfunction, and suicide. In addition to these psychological afflictions, they also face social exclusion, community rejection, and stigma which negatively feedbacks onto their somatic symptoms. Current psycho-social support is carried out by local health care workers and hospitals that provide individual and group counseling, as well as home visits. Nonetheless, the outcome for many of these women is poor, as many end up abandoned or at very low socio-economic status and lacking support or job opportunities. Without a doubt, rape shatters women’s lives and uproots communities in significant ways. This type of discriminating environment not only halts recovery for women but in some cases can actually feel as traumatic as the sexual violence itself!

What option do women in the eastern Congo have to stop sexual violence? Considering they live in a culture that does not readily accept rape survivors and mental illness is stigmatized, the task seems daunting. It is not my intention to enumerate the various steps that need to happen in order to improve the situation for women in the eastern Congo, but I will address this question in terms of their mental health needs. In the short-term, humanitarian efforts should focus on training more healthcare workers to focus on diagnosing women and relatives dealing with PTSD, and this can only be achieved through a campaign that dually addressed the problem of the under reporting of rape. Under reporting is a huge problem in this region resulting from a failed judicial system and states, as well as cultural bias and stigma associated with rape within a society, all of which perpetuate a culture of impunity for the perpetrators of sexual violence. However, this problem opens another can of worms that the current state of DRC cannot adequately address. A national police force reform would improve the rates of rape reports since presumably justice could now be achieved, but the feasibility of this task is questionable.

Additional interventions should address gaps within the health care system as a result of years of armed conflict. This disruption of health services and lack of capacity of the health system to deal with victims of sexual violence necessitates attention. Rape victims often require medical attention for treating physical traumatic complications such as fistulas but in the eastern Congo there are very few referral hospitals and health centers that offer services for women. Unfortunately, this lacking infrastructure is only one part of the problem, as psychosocial services for survivors are even more lacking. Focus groups among the community should work to encourage women to report rape and receive medical attention as soon as possible, while also raising awareness about the issue in order to reduce discrimination and stigma. This will promote the healing process for women and also encourage a culture of social responsibility within the community.

It goes without saying that sexual violence is a grave affront to human dignity and places a huge emotional burden on its victims. Women are by far more affected by the various forms of sexual violence and this demands a collective response from citizens on the ground as well as humanitarian intervention, such as developing and expanding programs, policies, and protection strategies that improve access to basic health care with a focus on sexual violence and mental health. Considering the cultural context, local women may be poised as the best sources of support services for women and family members with PTSD, and awareness-raising programs that focus on lowering discrimination against rape survivors, educate women on how to avoid risky situations, and highlight the importance of seeking medical attention as soon as possible after rape are key strategies.

Sources:

-DRC- http://en.wikipedia.org/wiki/Democratic_Republic_of_the_Congo

- Sexual Violence Increasing in DRC- http://www.thelancet.com/journals/lancet/article/PIIS0140673608600513/fulltext

-Shifting the Burden of Shame- http://icmhd.wordpress.com/2010/08/19/shifting-the-burden-of-shame-justice-for-survivors-of-sexual-violence-in-the-drc/

-DRC: Drumming for Deliverance- http://www.peacewomen.org/news_article.php?id=2768&type=news

-Sexual Violence in the Protracted Conflict in DRC- http://www.conflictandhealth.com/content/3/1/3

-Rates of Sexual Violence are High in DRC- http://www.guttmacher.org/pubs/journals/3621010a.html

Mental Health and Sexual Orientation in Young Women

February 10th, 2011

This week I decided to take a look at sexual orientation and subsequent outcomes in young women. It is often falsely assumed that homosexuality is part of the pathology of mental disorder and that in and of itself it is a mental illness. (Herek, 2007) Yet still 30 years after its removal from the DSM as a classified illness, even mental health practitioners still make this assumption and base differential treatment on a patient’s sexual orientation, rather than the social and environmental interactions that are mitigating factors. It is important that we see sexual orientation as another minority characterization and likewise it comes with its own set of risk factors.

Minorities in most societies often encounter minority stress, where they experience and then subsequently internalize events and victimization in their social environment. Internalized issues often are expressed externally as depression and other mental health problems. In the case of lesbian, gay, and bisexual youth, correlations have been made with symptoms of depression, mental health problems, and sexual health risk, including transmitted infections, HIV, and adolescent pregnancy. Furthermore, in general they often have considerably higher health disparities (Ryan, 2009) and they report more rates of suicidal ideation and attempted suicide in comparison to their heterosexual peers (Silenzio, 2007).

Why the higher rates? Sexual orientation has been independently associated with suicidal behavior and therefore cannot be the way we go about answering this question. Perhaps it is it can be answered by taking a look at the different markers for suicidal behavior that occur between LGB and non-LGB individuals because these markers may have different interactions with sexual orientation. This will also help us find more appropriate interventions.

Ryan et. al focused on family acceptance (read: let’s look at the kinship networks available) in a 2009 study on sexual orientation and mental health. They found that “negative family reactions to an adolescent’s sexual orientation are associated with negative health problems in LGB young adults”. It is important that we, as future advocates, help families become aware of and decrease rejecting behaviors that often influence the mental health problems of LGB youth.

Hereck et. al focused on the coming-out process (read: autonomy in deciding very important life decisions). Coerced or forced, LGB individuals may have amplified “feelings of vulnerability, alienation, and exposure that are often encountered during the coming-out process”. Again it is important that we, as future advocates, help LGB youth feel safe and ready in their coming out process in the hopes that we do not compound the ever present effects of societal stigma by creating an atmosphere that encourages internalized self-stigmatization and negative self-attributions.

Finally, Needham & Austin (2010) considered parental support again but this time from the perspective of gender. They found that lesbian and bisexual women reported less parental support during their adolescence and coming out period than their peers, and the same was found in gay men but in contrast to the generic results of Ryan et. al, Needham and Austin noted that bisexual men did not report lower parent support than their peers. Furthermore they found bivariate results in health-related outcomes with socio-economics having an impact as again did gender. Both lesbian and bisexual women reported negative health outcomes, while the only association with negative health that men had were with suicidal thoughts and that was only for gay men—there were none for bisexual men.

What this all says about mental health and sexual orientation in young women is yet again we, as a society (on a smaller scale in families as well), are negatively skewing the outcomes of disorder towards women. If we can make the slightest of strides towards acceptance for men, then we had better do it for women.

Work Cited

Herek, G.M., & Garnets, L.D. (2007) Sexual orientation and mental health. Annual Review of Clinical Psychology, 3: 353-375.

Needham, B.L., & Austin, E.L. (2010). Sexual orientation, parental support, and health during the transition to young adulthood. Journal of Youth Adolescence, 39: 1189-1198.

Ryan, C., Huebner, R.M., Diaz, M., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and latino lesbian, gay, and bisexual young adults. Pediatrics, 123: 346-352.

Silenzio, V.M.B., Pena, J.B., Duberstein, P.R., Cerel, J., & Know, K.L. (2007) Sexual orientation and risk factors for suicidal ideaton and suicide attempts among adolescents and young adults. American Journal of Public Health, 97(11): 2017-2019.

Mental Illness and the Promise of Innovation: a Marketing Challenge?

February 10th, 2011

In my last post I explored the differences between Western and Non-Western conceptions of mental illness; now I wish to segue way into a discussion of the need for developing mental health infrastructure that better addresses the needs of Non-Western societies. With this post I aim to first demonstrate the ways that mental health has been overlooked as an important public health concern and how new innovative programs can hopefully bridge that gap in order to better incorporate mental health services into the medical system.

Mental health services are very much integrated into the general medical system in many developed countries and this effectively helps refer and treat patients suffering from mental health issues. At the same time, a WHO report states that most serious mental disorders are being left untreated and by and large, developing countries fare much worse in this field, finding that 76-85% of those surveyed and had suffered from a serious disorder had never received treatment (1). One explanation for this discrepancy between those receiving treatments rests on the misallocation of funding.

The reality is that there is a very high prevalence of mental disorders in poor countries and this demands an affordable way to treat these people. Mental health is the “invisible problem” of international development. WHO estimates it to be the leading cause of ill health and disability globally, yet there is an incredible lack of interest from governments, NGOs, and foundations/charities (2). Common mental disorders are depressive and anxiety disorders that account for an important cause of increased morbidity and disability throughout the lifespan. Using disability adjusted life years (DALYs) to compare different health conditions shows that mental health disorders account for an estimated 14% of all global health conditions, yet they receive less than 1% of a country’s healthcare budget (2). So, why is there such a lack of global interest in this cause? It appears that mental health just isn’t “marketable” enough for the general public. Interestingly, NGOs to some degree allocate funds depending on how well the project will be received by the public, and research indicates that people will donate twice as much if they can empathize with the issue, usually through a captivating image of the problem as opposed to stark statistics (3). There could be some benefit in using better marketing strategies to project a more “public friendly” image of mental illness and thereby raise funds and attention.  Although I don’t think this is the best or only strategy, I recognize that compelling media strategies could play a pivotal role in advancing mental health services for people in developing countries. Additionally, increasing epidemiological research on mental illness that further illustrates the high burden of disease among the poor would be another way to divert some health funding to treatment programs.

The next step involves the challenge of addressing mental health in places where resources may be low and among a culture that may not recognize mental illnesses. Like I mentioned in my last post, some communities still view mental disorders as a misfortune in a family or a punishment from God and rely on spiritual healers for treatment, whom often interpret mental illness as a curse or demonic possession. This in turn prevents many people from seeking out treatment and this associated stigma further inhibits organizations from being able to raise funds for mental health. What is more, in light of the reported human rights violations of patients who are commonly restrained and denied basic rights, we can see how enacting policies for mental health will definitely require overcoming many cultural barriers (2).

Vikram Patel, Professor of International Mental Health in London and  a psychiatrist based in Goa, states that the first step in assessing this situation is to confront the “treatment gap”- the gap between the number of people with disorders and those receiving treatment, which is as high as 70-80% in many countries (4). He declares that developing countries must work to develop their own system that suits their current situation, “Developing nations must stop aping the North’s mental health services and use strategies tailored to their own needs. A key problem is that mental health services in developing nations imitate those in the West, where specialists in clinics or hospitals treat patients. This works well when there are enough specialists, and importantly, enough hospitals. When both are in short supply, more innovative thinking is needed,” (5). I think his argument is very powerful as it demands the recognition of mental disorders as an important public health concern, akin to infectious diseases and chronic diseases, but also advocates for a unique approach in low-resource areas. Patel continues to argue, “because of scarce mental health resources and their ubiquitous distribution and inefficient use, developing countries will never be able to close the treatment gap in any significant way if business continues as usual,” (5). Focusing only on hospitals and specialists is not the best option for developing countries that do not have the adequate resources, infrastructure, or high pay that developed nations boast.

Knowing that half of all countries only have one psychiatrist per 100,000 people, and a third of all countries have no mental health programs at all further supports the need for alternative approach to mental health (2). A great way to assist developing countries is to support the development of an approach that deals with mental illness in a culturally sensitive way and responds to low resources through training informal health workers. Indeed, randomized studies indicated that interpersonal therapy delivered by trained and supervised lay people was found to be an effective treatment for depression in rural Uganda (5). Training health workers and traditional healers to treat patients in poor countries and refer severe cases to a hospital psychiatrist may prove to be a more efficient way to treat more people suffering from mental disorders in low-resource settings.

For our part, a large amount of work remains in advancing the status of mental heath through policy advocacy and changing conceptions of mental illness worldwide, possibly through media and marketing campaigns. Aside from garnering increased global interest and funding for mental health, supporting developing countries to design innovative programs can hold the greatest potential for addressing this seriously neglected public health concern.

Sources:

1. WHO Report- http://un.by/en/who/news/world/2004/04-06-04.html

2. Mental Illness and the Developing World- http://www.guardian.co.uk/commentisfree/2010/may/10/mental-illness-developing-world

3. Getting to the Point- http://www.nonprofitmarketingblog.com/comments/sticky_week_iv_emotion_and_calculation/ 

4. Vikram Patel- http://www.lshtm.ac.uk/people/patel.vikram

5. Mental Health in the Developing World- http://www.scidev.net/en/opinions/mental-health-in-the-developing-world-time-for-inn.html

The A-Word: Abortion and the Mental Health of Young Women

February 3rd, 2011

As I rode my bike through white plaza two weeks ago, I was reminded that almost 4 decades later Roe v. Wade remains unresolved in the United States. I was on my way to practice and I thought to myself, ‘No need to stop ‘cuz that’s one debate I will never engage in…it’s a losing battle on either side as very few people are willing to budge on either way and find middle ground…although in all fairness there really is no middle ground’. I sighed and continued on my nonchalant way to practice, never thinking that I would ever contribute to the conservation on The A-Word. Yet here I am today blogging about you guessed it—Abortion.

I decided to discuss abortion not to change anyone’s mind, nor even to express my own opinions about abortion, but rather to address it from the perspective that we all too often hear about: guilt and regret. Guilt and regret are often expressed clinically as varying mental disorders including substance abuse, aggression, anxiety disorders, hostility, low self-esteem, depression and bipolar disorder in both genders. Nevertheless, I wondered if actual, quantitative correlations exist between abortions and mental disorders, especially in young women from ages 15-25. Furthermore, as I have posted before, young women at the onset of puberty are inclined to increased rates in internalized mental disorders, and being in the throes of an unwanted pregnancy only compounds things. Add some kerosene to the fire with emotions of guilt and regret if they decided to have an abortion, and one can only think that a young woman in this instance would be very unhealthy. This line of thought isn’t as cut and dry as it seems, as this leads to two opposing questions:

1.     Are mental health disorders causing young women to be more inclined to seek out abortions?

2.     Are abortions leading to or increasing the rate of mental disorder in young women?

I decided to do some research cross-culturally and I found some very interesting answers.

In New Zealand, abortions are free and legal for all ages, but abortions are legal only after you have gone to your doctor and 2 referred specialists confirm one of five situations in order to proceed with an abortion: the pregnancy would seriously harm the life, physically or mentally of the woman or baby; the pregnancy is a result of incest; the woman is severely mentally handicapped; abortions based on age considerations; or rape. Parental consent is not required for women under 16 and counseling is required for all women. (Fergusson, 2006)

Fergusson et. al. conducted a study in 2006 in Christchurch to find more concrete evidence on the correlations between abortion and mental health disorders in young women. The prevailing evidence showed weak correlations or non at all, but alas there were flaws in their designs, sample sizes, follow ups and they often failed to control for confounding variables including previous mental health disorders, personality, and childhood and family factors. More often than not, these same studies failed to compare mental health disorders in pregnant women 15-25, who choose or were not exposed to the idea of an abortion (including not wanting an abortion) to the young women who did and thereby failed to provide a reference point to determine the reliability of their correlations. (Fergusson, 2006) Fergusson et. al. took these limitations into account, corrected for them and even separated their samples into “Not Pregnant”, “Pregnant But No Abortion”, and “Pregnant Abortion”. They found that overall there was a significant correlation between pregnancy and rates of disorder (except alcohol dependence). However, it was highest among those having abortions and lowest among those women who had not had an unwanted pregnancy. When controlling for SES, family history, childhood, and personality, in comparative pairings those who never had unwanted pregnancies or became pregnant and never sought abortions generally showed a similar pattern of disorder, but those who had abortions had a significantly higher rate of disorder than their peers in both groups (except for anxiety disorder where their rates were only significantly higher than the pregnant no abortion group). Those young women who had abortions appeared to be at moderately increased risk of both concurrent and subsequent mental health problems when compared with equivalent groups of pregnant or non-pregnant peers.

In Ireland, Patricia Casey looked to answer these questions about abortions among young women:

1.     What is the usual emotional reaction to abortion?

2.     Is there a specific psychiatric disorder-associated abortion?

3.     Is abortion associated with an increase in mental health problems and, if so, is the relationship a causal one?

4.     What psychiatric disorders are associated with abortion?

5.     Does abortion impact on social outcomes such as education, employment and relationships?

6.     Does terminating an unwanted pregnancy help women’s mental health?

7.     What therapeutic interventions are available when a woman has an adverse reaction and do these have an impact on subsequent life outcomes?

Abortions in Ireland are illegal unless the pregnancy is in threat of endangering the life of the woman. While Casey herself did not do a study, she did look at over 2 decades of research and created a 2010, meta-analysis of sorts with only those that truly controlled for the limitations Fergusson et. al expressed above. Interestingly enough, she found that women’s emotions ranged from distress and guilt to relief and freedom. In the case of the former, it was often preceded by relief and then followed by the negatives feelings within a month and increased the rates of mental disorder increased significantly as more time elapsed. In the case of the latter positive emotions, a 9-year study found that positive emotions were associated with better support systems and the society that they lived in supported their decision, while negative emotions were associated with the opposite.

Casey also found some research that pointed to a potential causal link between abortion and mental health disorders, but we will never know as a study that would best address this question would be a randomized design that would prove highly unethical. On a more interesting note, in answering if abortions have any benefit, women refused abortions who subsequently had their child did increase or play a role in increasing unwanted mental health. Finally, it should be noted that as time has progressed research has begun to show women who have abortions having similar symptoms and disorder as patients with PTSD to the point that they now have dubbed Post Abortion Syndrome (PAS) mental disorders associated with abortion.

Then this year in Denmark, Munk-Olsen et al. found that the rate of psychiatric disorders did not increase after a first-trimester induced abortion in young Danish women. There was no immediate data available for any Asian or African countries. Nonetheless, how are there so many conflicting answers cross-culturally?

I think this is best answered by Major et. al’s American version of what Patricia Casey did in Ireland. Mental health disorders in young women who have unwanted pregnancies are a result of a number of variables. Her life before and after the pregnancy and abortion make a huge impact on her subsequent mental health. A young woman’s decision is compounded by the prevailing society ethos and social networks…just like the conclusion Casey arrived at. (Major, 2010) With this in mind, I have formed my own opinions on abortion and mental health disorders and I hope I will have helped others to do so as well.

Works Cited

Casey, P.R. (2010). Abortion among young women and subsequent life outcomes. Best Practice & Research Clinical Obstetrics and Gynaecology 24, 491-502.

Fergusson, D.M., Horwood, L.J., Ridder, E.M. (2006). Abortion in young women and subsequent mental health. Journal of Child Psychology and Psychiatry 47 (1), 16-24.

Major, B., Appelbaum, M., Beckman, L., Dutton, M.A., Felipe Russo, N., & West, C. (2009). Abortion and mental health: evaluating the evidence. American Psychologist Association 64 (9), 863-890.

Munk-Olsen, T., Munk Laursen, T., Pedersen, C., Ldegaard, O., Mortensen, P.B. (2011). Induced first-trimester Abortion and Risk of Mental Disorder. The New England Journal of Medicine 364, 332-229.

Interventions: rescuing girls from Cambodian brothels

February 3rd, 2011

Going Undercover…Is it an effective intervention? What are the dangers? What are the drawbacks?

For the next few blog posts, I plan to explore the various interventions, in the hopes of building an optimal solution to the sexual exploitation of women and children in Cambodia. I learned of one dramatic intervention through Chris Hansen’s Dateline NBC report. He spent a year in Cambodia, undercover with the Dateline team, partnered with the International Justice Mission, a human rights group, investigating Cambodian brothels and trying to free women and children and prosecute pimps and brothel clients.  Gary Haugen, a former federal prosecutor who runs  the IGM. Haugen’s group “sends his investigators undercover to gather evidence of sex slavery in other countries, then takes the evidence to local authorities to persuade them to take action. Their work helped rescue hundreds of women and children around the world,” according to Hansen.

“The prey is plentiful” in many Cambodian villages, Hansen said, after visiting brothels, horrified by “the ugliest, most preventable man-made disaster on our planet today.” In Cambodia, where the average income is less than $300 per year for most families, children are often sold by their own parents. Or, as I discussed in my last post about conditions in brothels, they are lured by what they think are legitimate job offers, but tricked into prostitution. Some brothel are even owned BY women (This is really hard for me to understand). One woman, “Madam Lang,” told the investigators that she sells young virgin girls for $600, and clients can take the girls back to a hotel for up to 3 days.

NBC’s hidden cameras exposed the many failed attempts of girls to escape the brothels; surviving an escape is next to impossible. Another shocking piece of the intervention was the discovery of many American men who pay to have sex with the young Cambodian girls. Once caught, they are being investigated by the US and face severe consequences. Colin Powell urges Americans to take action to stop the sex trade in Cambodia, because “if we want to have better relations with the countries of the world, we have to help them with this kind of problem.” The US can use sanctions to pressure countries that aren’t taking enough action. Though we haven’t yet seen significant progress from these policies, and the problem may be impossible to eradicate completely anytime soon, Powell believes that political pressure is the right approach.

Mu Soc Hua, Cambodia’s minister of women’s affairs, estimates 30,000 children are enslaved in the sex trade. This horrifying number inspired Haugen to plan a raid on a brothel in one small village. The plan involved “tricking the pimps into bringing the girls to a supposed sex party at a house outside the village.” They hoped that there, it would be easier for the police to arrest the pimps, rescue the children, and shut down the brothel. Through deception, delays, and persistence, the plan finally worked. These interventions can be particularly risky because one never knows if the police can be trusted. “Many of the cops are in the pimps’ pockets,” even though the Cambodian police have a unit for prosecuting sex trafficking.

The raid yielded the arrest of 12 pimps and madams, the rescue of 37 girls, and the horrifying realization that to solve the problem, not only must we prosecute the people who sell the children, but also the tourists who supply the demand. Luckily, agents in the US Department of Homeland Security are investigating the horrendous purchases of Cambodian girls and women made by American tourists. How can we send messages to the men in our country that are feeding the sex trafficking crisis around the world?

Furthermore, even though the “rescue” component of this intervention was tremendously impressive, but what happens to the girls AFTER they are rescued? If they’re lucky enough, they’re taken to AFESIP centers, such as Somaly Mam’s home for girls. Rescued children and women cannot just be “released into the wild” per se, but need counseling, medical care, education, and support to learn to live independently. This transition to the real world must be done in a safe and nurturing environment, because many escaped sex slaves are paranoid of the world around them, untrusting of all men, and have such low self-confidence that they don’t realize they can make decisions for themselves about their bodies and their lives.

Works Cited:

Hansen, Chris. “Children For Sale.” MSNBC. 9 Jan. 2005. Web. 2 Feb. 2011. <http://www.msnbc.msn.com/id/4038249/ns/dateline_nbc/>.

What is normal? Conceptions of Mental Illness and Stigma

February 3rd, 2011

The stigmatization of people with mental illnesses is well documented and the negative effects are understood to be detrimental to health outcomes. I think that in order to develop an effective approach to dealing with mental illness across societies, we need to better understand different conceptions and the reasoning behind treatments. I would like to delve into this problem because I think it will help inform the conversation on mental illness and the need for a transcultural approach to mental health interventions, which I will also discuss further in my end-of-the quarter policy blog post.

Before we can get into the effects of stigma on treatment in different cultures, we need to take a look at the different conceptions of mental illness. What is normal? By virtue of belonging to a particular society, culture provides an individual with a set of guidelines telling them how to view and experience the world. Because of this reality, we are confronted by many different (and arguably valid) interpretations of what is normal and abnormal. Mental illness is applied to behavior that is both abnormal and outside the norms of society (1). I think this certainly complicates the development of a universal approach to diagnosing and treating mental illness, but the dominance of Western conceptions of mental illness has enabled such an approach. And while the exact causes of mental disorders remain unknown, the research from Western psychiatry supports the notion that like many physical ailments, mental disorders have inheritable biological dispositions that can be triggered by various environmental factors like stress and poverty.

The ways that different cultures view mental illness influences their diagnostic systems and treatments.

Western conceptions of mental illness tends to locate the problem with the individual and psychoanalysis also reduces illness to experiences confined to the mind of the individual. Analysis of mental health in Western cultures suggest a strong relationship between severe mental disorders in adulthood and abuse/neglect in childhood. Although, with the increased understanding of mental health, different models have emerged to shed light as to how a mix of biological, psychological, and social factors interact to explain disorders; this is the primary paradigm of Western psychiatry (2). Additionally, there is a high priority on confidentiality, reflective of our Western values of discretion and keeping “private” matters from the public domain which later influence societal attitudes about mental illness.

Diagnosis is based on standardized DSM-IV measures developed by the American Psychiatric Association, and treatment involves a combination of medication, psychotherapy, and other personalized recommendations. This combination of medication and therapy helps reduce the symptoms of patients suffering from delusions and hallucinations, while also reframing the way they perceive their mental health. The therapy helps create a connection with the patient that allows them to understand the nature of their illness and how they can work to resolve life problems that exacerbate the illness (3).

Non-Western conceptions of mental illness are varied but the problem is seen as belonging to the community as a whole. Essentially, where Western societies would focus on looking within the individual to find a problem and solution, we will see that in many societies the spiritual dimension is of central importance. For example, it is not uncommon for some cultures to report seeing or hearing a recently deceased person within the first month. These differences also come into play when people present their problems to the community. In many cases, mental issues are commonly expressed through physical complaints than mental symptoms. Additionally, treatments for the mentally ill usually involve the entire family (1).

In these cultures, diagnosis is different since symptoms are not described in the way we normally perceive mental health issues, but instead as physical ailments. When the problem persists, as is the case for most affective mental disorders, people run into various barriers to quality care. The lack of psychological support has forced the handful of psychiatrists in countries like Ghana and Ethiopia (working under Western models) to coordinate efforts with the more prevalent “prayer camps” which are most common in rural villages where mental illness is still perceived as a spiritual problem (4). Since government-run psychiatric programs are severely understaffed and have limited resources, many have suggested sending community health workers to the prayer camps to begin bridging services and establish a more cohesive approach. While there are many reports of inhumane treatment of patients in these camps (patients are sometimes chained to prevent violence/running away), it must also be explained that the idea of psychotherapy can be seen in this context as well. The “healer” communicates to the sufferer and attempts to emotionally engage the person and create a narrative, which reframes the problem of the individual in terms of the myth.

While similarities can certainly be found across societies, the description of symptoms and signs will be specific to the society. An example of this would be schizophrenia between an American patient and someone from Ethiopia. While one may claim that conspiring government agencies are controlling her thoughts, the other might believe that demons or black magic are tormenting her mind.

So lets talk about stigma. In Western societies, mental illness were perceived to be private matter (with many patients historically having to be confined to mental institutions), and so it goes without question that this led to a high level of stigma embedded in society. Stigma can manifest itself in many forms and negative societal attitudes result in misinformation that can affect how others perceive the mentally ill as well as how they perceive themselves. What is more, the way the media depicts mentally ill patients perpetuates an image of incompetence, violence, and irrationality. These negative depictions can therefore affect people seeking treatment for problems and also lead to discrimination. Stigma increases the suffering associated with mental disorders and many social movements and patient advocacy groups are now focusing on increasing awareness and acceptance among society in order to reduce stigma and discrimination associated with mental illness (2).

Mental illnesses are stigmatized in some form or another in nearly every culture, but the case of stigma goes beyond discrimination and prejudice in few cultures. In many African countries, the idea of mental illness is still not regarded as a mental disability at all, but rather a spiritual flaw within the person. Misconceptions and superstitions run rampant in many of these societies, leading to very poor quality treatment of people suffering from affective mental illnesses like schizophrenia. Most people do not believe that mental illnesses exist, but instead attribute it to spiritual problems within the person, black magic, or demons (5). There are various neurological aspects of mental illness that are overlooked in rural villages and since there are only a handful of psychiatrists, families tend to take treatment into their own hands.

The stigma associated with the causes of mental illness inhibits the improvement of treatments and allow controversial practices to continue.  In order to improve the health outcomes for people suffering from mental illnesses in these societies, work must center around better integrating psychiatric care in the general health system and helping train more community workers to diagnose, treat, and refer patients in rural villages affected by mental disorders (6). Social movements that raise awareness of the nature of mental illness would definitely be beneficial as they would increase overall acceptance within a society and thereby diminish the level of stigma and discrimination that often exacerbates the effects of these disorders.

What does all this mean for the future of conceptions of mental illness? What I attempted to do was bring to the forefront the massive amount of variation that exists between 1) conceptions of mental illness, 2) associated stigma across cultures, and 3) current methods for addressing the issue across cultures. This information becomes crucial as societies work to consider what the best medical interventions are for people suffering from severe mental illnesses and how to raise their standard of living by understanding the detrimental affects of stigma. It is my hope that this post enlightens some of you on the complexities of mental illness across cultures and also provides background for my future post on how to best address the issue through policy.

Works Cited:

(1) Cultural Factors in Psychiatric Disorder- http://www.mentalhealth.com/mag1/wolfgang.html

(2) Mental Disorder- http://en.wikipedia.org/wiki/Mental_disorder

(3) American Psychiatric Association: Mental Illness- http://www.healthyminds.org/Main-Topic/Mental-Illness.aspx

(4) BBC News: ‘Prayer Camps’ Chain Mentally Ill- http://news.bbc.co.uk/2/hi/africa/8040057.stm

(5) Perception of Stigma in Rural Ethiopia- http://www.springerlink.com/content/5bup0ql1ewtn46dc/

(6) WHO: mental health and substance abuse- http://www.who.int/countries/eth/areas/mentalhealth/en/index.html

Addressing the Pyschological Trauma of Sex Trafficking Victims

February 2nd, 2011

The term Post Traumatic Stress Disorder (PTSD) has been at the forefront of the field of psychology since the late 1960s, when veterans returned from the Vietnam War with severe cognitive impairments (Sadruddin). Studies over the years have shown that the greater the degree of violence, especially interpersonal violence, and the greater the lack of control, the higher the risk of long term mental health problems (Sadruddin). Victims of sex trafficking, particularly minors who are likely lacking in healthy prior relationships, are the perfect example of a PTSD “at risk” population. According to the a report by the Stanford Policy and Law Review, “severe physical assaults, imprisonment, gang rape, and other forced sex are the most notable types of severe traumatic events known to lead to PTSD” (Sadruddin). Thus, while sex trafficking victims seem to possess all the qualities necessary for strong PTSD, conditions such as family and social support, which often help to decrease the effects of the disorder, are usually lacking in this population.

Since the Trafficking Victims Protection Act was signed into law in 2000, there has been a growth in the means of addressing domestic human trafficking but the needs are far from met. According to an article written in the Human Rights Quarterly, “the evolution of organizations that serve trafficking survivors is occurring quickly and eclectically” (Shigekane). While organizations that traditionally serve refugees, sex workers, or domestic violence survivors are opening their doors to trafficking victims, they do not have the training or resources to be able to meet the needs of this very unique population.

Domestically trafficked girls experience a different kind of abuse and trauma, and thus often need more attention, 24-hour security, small groups, counselors who understand their specific situations, and peers that have had similar experiences. Some professionals believe they need an all-female environment, while others believe male staff should be present, but not in direct contact with the victims until the later stages of their recovery (Clawson). Also, with the continued stigma surrounding prostitution, the victims, even minors, are often viewed as at fault. It doesn’t help that many either blame themselves, or do not see the wrongdoing of their perpetrator at all. Referred to as “trauma bonding,” a form of Stockholm Syndrome, the girls believe they are in love with their trafficker and need to return to him, either because out of love or out of fear. This is a central factor leading to the high rate of runaways observed in less secure facilities such as homeless shelters and foster homes (Clawson). However, although the last decade has seen a shift in the classification of sex trafficking minors from criminals or “prostitutes” to victims, the US Department of Health and Human Services reports that there has been a “huge paradigm shift that has occurred in statute, but not in practice” (Clawson).

While there are unfortunately only about eight shelters for sex trafficking victims nationwide (housing anywhere from 6 to 24 girls at a time), they all seem to have the same overall understanding of what the victim needs. First off, victims of sex trafficking often require more time in the shelter than domestic violence victims in order to fully recuperate from their trauma (Shigekane). This could be due to the lack of independent living skills and need to adjust immigration status, or on the other hand, the long recovery period required for victims of Stockholm Syndrome. In both situations, girls need to re-learn how to form trusting relationships and re-gain self-esteem in order to realize that they are more than their ability to please men. In the former, however, immigrant girls have a whole separate set of issues on top of their new psychological disorders. Paying for interpreters, especially for remote languages, is very difficult for organizations, and framing the recovery plan around specific cultures is an important yet inherently difficult necessity.

While many more shelters and organizations are needed to adequately address the unique circumstances of this population of children, what can YOU do as an undergraduate (or graduate student) in your community?

One of the most challenging obstacles to helping these victims is actually identifying them. Due to the very underground nature of this industry and its new-found outlet in the internet, it is up to community members and professionals to know what to look for- in an airport, on a street corner, or even in a homeless shelter or soup kitchen (where men or young girls often go to recruit “new meat”). The link below lists all of the signs you should be looking for when in large, public places. Just a few weeks ago, an 8-brothel sex ring was discovered in Santa Clara County thanks to an anonymous call from a community member who thought something was “off” about her next-door neighbor. This could be you. The hotline to call is in the top right hand corner. Put it in your phone, just in case.

Know the signs so we can help eliminate this awful industry from our own backyards.

http://www.polarisproject.org/human-trafficking/recognizing-the-signs

The Life of a Sex Slave

January 30th, 2011

Forced to drink a male client’s urine. Bitten by fire ants. Whipped with an electric cable. Burned with hot metal rods. Stuffed with hot chili pepper flakes. Deprived of basic medical care.

Because she dared to ask for a rest from clients. Because she was bleeding and vomiting. Because she is female.

According to the Human Rights Task Force on Cambodia’s 2001 report, “the inadequacies in the law and legal system and the serious violations to the health and human rights of women in sex work” stem from three main social factors:

  1. stereotyping of women as providers of pleasures to men, a role that is reinforced by the media’s depiction of women as sex objects
  2. unequal access of women to education, resulting in the marginalization of women to work such as prostitution, where educational qualification is not necessary of pleasure to men
  3. societal ostracism of commercial sex workers, make it difficult for them to seek assistance for their health and security needs

Even though prostitution and human trafficking are illegal in Cambodia, “officials are often paid to look the other way” (Marie Claire). Sreypov Chan was 7-years-old when her mother sold her to a brothel in Phnom Penh. If she didn’t meet her quota of men for the day, she was shocked with a loose wire from a socket in the wall. This horrendous physical abuse was coupled with verbal and emotional harassment, which have permanently scarred Sreypov, leaving her terrified and skeptical of men. Sreypov escaped at age 10, after living a slave in Phnom Penh’s most notorious sex district, the “White Building.”  She succeeded in fleeing from the brothel on her third attempt; she ran into a man on the street who brought her to the police station. Often, police officers return girls to the brothels. Luckily this time, they called Somaly Mam.

Sreypov was relatively fortunate, in that she was only enslaves for 3 years. For many girls and women, a brothel is their permanent residence, because they feel they cannot escape, or they are too physically weak or hopeless to try. Most sex workers start under the full control of the brothel operator, which means they are treated as slaves. They are not paid for their labor. When girls first arrive at the brothel, they are often given more food, clothing, and freedom of movement than they will ever enjoy again. Many girls start out doing household chores or cleaning when they first arrive at the brothel; this deception allows brothel owners to lock up the girls before they think to escape, especially if they are young and particularly unaware of the reality of their situation. Once a girl has serviced her first client, she becomes a prisoner to the brothel owner, and is forbidden from leaving the building unless guarded by someone. Some women gain back a little bit of this freedom when they have earned back their “purchasing price.” However, since there is no official accounting of how much a woman has earned (since most of the money goes directly to the pimp), women are “at the complete mercy of the operator as to when they can be “freed” from the purchasing bondage” (HRTFC).

Not only do sex slaves risk contracting STIs and HIV/AIDS, but they are also frequently beaten by their pimps, forced to live in cramped quarters with minimal sanitation, insufficient nourishment, and crippling psychological distress. Every day for these girls and women is filled with violations of human and health rights. Many women are forced to engage in unprotected sex, even when condoms are available, because clients often refuse to use them. Luckily, several condom interventions have been successful. Sreypov now distributes condoms and soap to sex workers. So much blame is placed on the sex slaves for spreading HIV, but “what is usually forgotten is that it is not the women sex workers themselves nor their work but the high risk behavior of their clients that has caused the spread of HIV/AIDS and other STDs” (HRTFC). A client who didn’t use a condom infected a sex worker in the first place, and the epidemic spread throughout Cambodia’s cities. Here’s a another great example of the dangerous intersection between education, health, and human rights.

Please watch the following clip for a vivid picture of the brothels: http://www.youtube.com/watch?v=aSDiMIgrd9A

The more I research, the clearer it becomes: the life of a sex slave is isolated, injurious, and paralyzing. The sex workers both depend on one another for support and compete against one another for favorable treatment by brothel owner. According to HRTFC, 84% of sex workers interviewed wanted to stop working in prostitution. It surprised me to learn that not everyone says they want to escape. They feel they have no other alternative, or have given up hope. Additionally, a woman’s status is forever tainted by her work as a sex slave, so they may never be able to marry. Women often feel that they have no other skills and have a better chance of earning a living as a prostitute than as a free woman. HOW can we CHANGE this attitude so that women feel empowered to believe in their worth as contributing members of society?

Works Cited:

Human Rights Task Force on Cambodia. “Cambodia: Prostitution and Sex Trafficking.” Human Rights Solidarity. 13 Aug. 2001. Web. 20 Jan. 2011. <hrsolidarity.net>.

Pesta, Abigail. “Diary of an Escaped Sex Slave.” Marie Claire. Web. 26 Jan. 2011. <marieclaire.com/world-reports/news/international/diary-escaped-sex-slave>.

♫ If you wanna be happy for the rest of your life/Never make a pretty woman your wife/So from my personal point of view/Get an ugly girl to marry you ♫

January 27th, 2011

When Jimmy Soul sang these lyrics in 1963, I am sure he had the best of intentions. He wanted every girl who was ever told that they weren’t pretty enough or who ever cried herself to sleep because someone had brazenly told her she was downright ugly to know that they shouldn’t be worried. At the end of the day she was a better catch than a pretty girl. The reason being she would never cheat, and certainly she was bound to be a good cook. Yes, his 1963-gender-biased song is easily retrospectively criticized, but how different is it from the current mantra we often tell our young girls in the hopes of deterring them from mental illnesses such as depression, eating disorders and anxiety disorders?

Don’t worry you don’t really want huge boobs anyways; yours will grow soon.

God gave you brains instead of beauty just use what you’ve got.

One day those girls will all be working for you.

Just like the well-meaning Jimmy Soul, we are ignoring the fact that a little girl, most likely on the cusp of puberty (which is arguably the most traumatic event in every girls’ life, where chaos is the norm with her body) is dealing with some difficult emotions and is basically being told to swallow them. Furthermore, we are completely ignoring the fact that even the pretty girls may have maladaptive issues with their changing bodies, and no one even bothers to consider that they too may be in turmoil. This is the well-meaning, but hazardous way we treat youth and adolescent girls that keeps them from addressing their mental illness early and thereby quickly abating the illness.

Keeping this in mind and after hearing Piya Sorcar’s guest lecture about the success of TeachAIDS it seemed that my blog post last week needed to be revisited. I decided to research interventions in mental health for youth and adolescent girls. Not just any interventions, but successful ones that were actually making a difference for young girls. I was hoping to bring about something positive perhaps even enlightening to a topic that when discussed seems to only thrive when we see images of the most depraved consequences of mental illness. We have been lambasted by images of eating disorders, depression, and other mental illness, as a way of promoting their awareness, but it is to the extent that we have become inured to these images and their shock value is no longer effective. It is about time we took a different approach to mental illness in general, but it is even more important that we take a different approach to mental illness in youth and adolescent girls because more often than not it affects the women they become and we lose their potential influence on the world.

The first article I encountered immediately began by restating much of what I have said and a bit more. “Most mental disorders begin during youth (12-24 years of age), although they are often first detected later in life.” (Patel et al., 2007) Furthermore [mental illness in youth and adolescents] is often correlated with other health and development discrepancies, including lower educational achievement, substance abuse, violence, and poor reproductive and sexual health. (Patel et al., 2007) Incidences of self-harm and suicide increase at these ages as well.

Patel et. al argued that despite there being several interventions to prevent mental illness available, even in developed countries, the rate at which the related mental-health care they receive fails to meet their needs is nearly 100%. Basically, these youth and adolescent are being ineffectively treated nearly 100% of the time. Yes, 100%. This is shameful especially in developed countries where access is less of an issue than in developing countries, and it is often because we tend to deliver healthcare in general for young adults in outpatient settings for adults. We need to be revise our interventions to have a youth-focused model and we also need to integrate mental health disorders into the spectrum of young adulthood diseases.

Subsequently, in Computers in talk-based mental health interventions I found a likely candidate for a youth-focused intervention. We are the generation of laptops iPhones, iPads, and digitized and hand-held everything. Why not use the object we use most as a assistive tool for mental health? Previous research, while limited, has shown the potential of technology in mental health settings. (Coyle, 2007) Current interventions including drug interventions are clearly not working as the majority of people suffering from mental illness do not receive the required or even adequate treatment. Therapists and psychiatrist on the other hand argue that this is an issue of access, but research has also shown that often patients with access do not want to open up with their doctors and thus fail to get adequate treatment. (Coyle) Selfishly, mental health workers are also worried that trying computer-based interventions will damage the patient-doctor relationship and even make it obsolete. However technological interventions and patient-doctor interactions are not mutually exclusive and instead computer based interventions should be seen as a tool to help adolescents open up more easily. This will certainly decrease the preponderance of adult mental illnesses and unnecessary drug interventions.

Technology and computer based interventions still needs much research, but anyone truly familiar with our youth and adolescents will know that they are often more prone to interactions when they are in an environment that is normal and replicates their everyday existence. So what’s the harm in trying?

Works Cited

Coyle, D., Doherty, G., Matthews, M., Sharry, J. (2007). Computes in talk-based mental health interventions. Interacting with Computers 19, 545-562.

Patel, V., Flisher, AJ., Hetrick, S., McGorry, P. (2007). Mental health of young people: a global public-health challenge. Lancet 269, 1302-1313.

Sex Trafficking in Vietnam: What does the United States see?

January 20th, 2011

I would like to begin my research on the issue of sex trafficking in Vietnam through the eyes of the United States of America.  With this outside-in approach, I hope to contextualize the issue of sex-trafficking: first from a global perspective, and then subsequently from the perspective of those directly involved in Vietnam.

Ever since the adoption of the Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, also known as the Palermo Protocol, in the year 2000, the U.S Department of State has released a Trafficking in Persons (TIP) Report annually for the last ten years in the effort to combat modern day slavery worldwide.  The TIP Report is compiled from information reported by U.S. embassies, government officials, NGOs, research trips, published reports, and individuals through email. The report serves as a way to monitor and combat human trafficking in two ways: 1) By placing countries into tiers based on the extent of governments to stop trafficking and 2) By suggesting government response through prevention, criminal prosecution, and victim protection.  The methodology used by the TIP Report assigns the following tiers:

TIER 1

Countries whose governments fully comply with the Trafficking Victims Protection Act’s (TVPA) minimum standards

TIER 2

Countries whose governments do not fully comply with the TVPA’s minimum standards, but are making significant efforts to bring themselves into compliance with those standards

TIER 2 WATCH LIST

Countries whose governments do not fully comply with the TVPA’s minimum standards, but are making significant efforts to bring themselves into compliance with those standards, AND: a) the absolute number of victims of severe forms of trafficking is very significant or is significantly increasing; b) there is a failure to provide evidence of increasing efforts to combat severe forms of trafficking in persons from the previous year; or, c) the determination that a country is making significant efforts to bring themselves into compliance with minimum standards was based on commitments by the country to take additional future steps over the next year

TIER 3

Countries whose governments do not fully comply with the minimum standards and are not making significant efforts to do so

In 2010, Vietnam was placed on the Tier 2 Watch List, a downgrade from its position in Tier 2 in the year 2009.  Because the tier system is organized according to how much a country is doing to combat human trafficking, this means that Vietnam is simply not doing as much as it should to address the issue of human trafficking (both sex and labor).  According to the 2010 TIP Report, not only does Vietnam not comply with the minimum standards for the elimination of sex trafficking, it does not show any effort to criminally prosecute and punish trafficking offenders or protect victims of trafficking.  Furthermore, the govern

ment has never prosecuted a single case of labor trafficking.  This is especially surprising because even though there has been an increase in labor exports in the recent past as Vietnam has tried to increase employment and eliminate poverty, the country has not put into place any laws or regulations on labor trafficking and labor recruitment companies.

It seems that Vietnam is placed in Tier 2 Watch List instead of Tier 3 because the government has promised to make some improvements. The government continues to do more in terms of cross-border sex trafficking, but has not addressed internal trafficking, which in itself could be a huge issue due to prostitution and the sex tourism industry.

As the TIP Report suggests, Vietnam still has a lot of work to do in terms of stopping human trafficking.  In terms of sex trafficking specifically, major problems include: 1) government funding for victim protection resources and shelters, 2) Education of police at the borders in recognizing victims and directing them to appropriate support, 3) Addressing corruption within the legal system, especially in terms of taking bribes to look the other way, 4) Increase criminal prosecution and punishment of all those involved in human trafficking to establish accountability, and 5) Address the issue of internal trafficking in addition to international trafficking.

The Vietnamese government has continued to make progress in some key areas of trafficking prevention with the help of international organizations, NGOs and foreign donors.  Some efforts include the distribution of brochures on the dangers of sex trafficking and child sex tourism, awareness campaigns, standardization of procedures for the repatriating of victims with Cambodia, and pre-marriage counseling.  However, it is very disappointing to me that even with these very few efforts, the government of Vietnam did not produce them on its own.  Most of these efforts were initiated and led by international organizations with private funding. What is the government of Vietnam actually doing? This topic I will explore in next week’s blog entry.

Sources:

1. Trafficking in Persons Report 2010: http://www.state.gov/g/tip/rls/tiprpt/2010/

2. “Trafficking Fight Lacks Political Will” by Radio Free Asia: http://www.rfa.org/english/news/vietnam/trafficking-12062010172500.html

3. “Vietnam’s global human trafficking an inhuman epidemic” by SFGate.com: http://articles.sfgate.com/2005-08-21/opinion/17386939_1_vietnamese-women-vietnamese-people-group-of-vietnamese-americans